Effectiveness of ceftriaxone versus cefoxitin in reducing chest and wound infections after upper abdominal operations.

A controlled randomized trial with blind assessment of end results is described comparing the efficacy of 1 g of intravenous ceftriaxone at induction of anesthesia with 1 g of intravenous cefoxitin (three times) administered every 8 hours starting at induction in preventing pulmonary and wound infection after upper abdominal operations. There were 150 adults who underwent biliary or gastroduodenal operations who were randomized to each protocol. A total of 123 patients completed the protocol--59 received ceftriaxone and 64 cefoxitin. Chest infection was defined as pyrexia plus clinical and/or radiologic signs of consolidation or the production of purulent sputum. Wound infection was defined as purulent wound discharge. There was a significant reduction (19% versus 42%, P < 0.05) in chest complications and in wound infection (0% versus 8%, P < 0.05) in the ceftriaxone group compared with the cefoxitin group. It is concluded that for biliary and gastroduodenal operations, 1 g of ceftriaxone is superior to 1 g of cefoxitin (three times) administered every 8 hours and that this effect is likely to be due to the prolonged bactericidal blood levels produced by a single dose of ceftriaxone.

Ceftriaxone is more effective than gentamicin/metronidazole prophylaxis in reducing wound and urinary tract infections after bowel operations. Results of a controlled, randomized, blind clinical trial.

A controlled, randomized trial with blind assessment of end points is described comparing ceftriaxone (1 g) given at induction of anesthesia with gentamicin (2 mg/kg) and metronidazole (500 mg) (GM), three times, every eight hours starting at induction, in preventing wound, chest, and urinary tract infections following bowel operations. Patients with inflammatory bowel disease received prophylaxis for five days. Two hundred sixty patients were randomized, and 196 were studied after exclusions. Ninety-four were given ceftriaxone, and 102 were given GM. Chest infection was defined as pyrexia plus clinical or radiologic signs of consolidation or the production of purulent sputum. Wound infection was diagnosed on the basis of purulent wound discharge or pyrexia plus swelling, redness, and pain around the wound, and urinary tract infection was diagnosed from microbiologic results. There was a significant reduction in wound infection (17 percent to 6 percent; P < 0.05) and in urinary tract infection (8 percent to 1 percent; P < 0.05) in the ceftriaxone group compared with the GM group. Chest infection occurred in 16 percent of the ceftriaxone group compared with 25 percent of the GM group, but this difference was not statistically significant. Infected patients were in the hospital more than four days longer than uninfected patients, a statistically significant difference (P < 0.01). It is concluded that ceftriaxone is superior to GM in reducing postoperative sepsis and that this effect is likely to be due to the sustained bactericidal blood levels achieved by ceftriaxone.

Prophylaxis against sepsis in patients undergoing major surgery.

Postoperative infection in general surgical patients is discussed according to operation types. A selection of the huge literature on each group is reviewed, and details from the author's own work and ideas are presented. By discussing these points attempts are made to determine the best regimens for a given set of clinical circumstances. There is a small literature indicating that postoperative chest infection can be prevented by some antibacterial drug regimens, and this question has been addressed; it seems that in the past it has been largely ignored. Some nonantibacterial methods of reducing postoperative infection are also briefly discussed.

Painless split skin donor sites: a controlled double-blind trial of Opsite, scarlet red and bupivacaine.

A prospective randomized double-blind trial comparing Opsite alone, Opsite after application of bupivacaine, scarlet ointment dressing alone and scarlet ointment after bupivacaine was done to assess the effect of these four dressing regimens on split skin donor site pain and healing. Significantly less pain was reported by those dressed with Opsite and this was thought to be due to the immobility of an Opsite dressing. Many of the patients dressed with scarlet ointment felt no pain. It was concluded that movement of dressings is the main factor in pain production and that bupivacaine appeared to have no effect. There was no difference in healing rates between those treated with Opsite and those treated with scarlet ointment. It is concluded that using Opsite is a convenient way of preventing donor site pain, but that to gain maximum advantage from this it should not be applied under tension.

Clinical trials are usually beneficial to patients and hospitals.

We examined the cost of antibiotics used prophylactically in the first 25 patients in a controlled clinical trial comparing different antibiotic regimens in the prophylaxis of sepsis. We compared this with the costs of prophylaxis in 25 similar patients immediately before the trial started and found that the costs in the pretrial patients were significantly greater than in the trial patients. The trial is therefore beneficial to the hospital. We also examined the dispensing errors in the same patients. We found none in the trial patients but there were 77 out of 627 doses prescribed in the pretrial patients. We concluded that the abolition of dispensing errors brought about by the trial must be beneficial to the patients. They were also benefitted by the close monitoring which reveals complications at an early stage, and the improved case notes. The Hawthorne effect on medical and nursing staff is the most likely cause of these phenomena.

Piperacillin in surgical infections: a clinical trial.

Piperacillin was administered in eighteen patients with mixed infections. Three had osteomyelitis, two had peritonitis, two had gangrenous toes, one had bronchopneumonia, and the other ten had leg ulcers of various types accompanies by cellulitis. In eleven patients one of the infecting organisms was Pseudomonas aeruginosa, and another had Pseudomonas maltophilia. All had appropriate surgical treatment, which in nine patients included skin grafting in the presence of Pseudomonas aeruginosa. All the patients were clinically cured except for one with osteomyelitis who relapsed and was found to have a residual sequestrum. None of the skin grafts failed. In other patient who underwent grafting, cloxacillin was also given because she had a beta-lactamase-producing staphylococcus. The only adverse reaction was thrombophlebitis of the vein used for drug administration in 15 out of 18 patients. One hundred and five other isolates of Pseudomonas aeruginosa were tested in the laboratory against piperacillin and resistance to the drug was found to be rare. It was concluded that piperacillin is a safe drug to use, is effective against a wide range of organisms, and is particularly effective in preventing the destruction of skin grafts by Pseudomonas aeruginosa. It is likely to be ineffective against beta-lactamase-producing staphylococci, and when these are present also, it would be wise to use another drug such as cloxacillin in addition.

The effect of dihydroergotamine and heparin on the incidence of thromboembolic complications following total hip replacement: a randomized controlled clinical trial.

A randomized blind clinical trial was carried out to assess the effect of dihydroergotamine (DHE) alone and in combination with heparin on the incidence of thromboembolic complications of total hip replacement. It was found that a combination of DHE 0.5 mg and heparin 5000 units subcutaneously, given 8-hourly in separate injection sites, reduced the incidence of thromboembolic complications from 63 per cent in the untreated controls to 7.4 per cent in the treated group. This difference was highly significant. DHE alone produced a reduction in the incidence of thromboembolism but this reduction was not statistically significant. Blood loss was calculated using pre- and postoperative haemoglobin levels, taking into account the amount of blood transfused. It was found that the blood loss in the DHE/heparin-treated patients was identical to that in the untreated controls. The patients who received DHE alone had a significantly lower mean blood loss than the other two groups. It is concluded that this reduction in blood loss by DHE may be due to its venoconstrictor properties.

The Auckland Hospital varicose veins and venous ulcer clinic: a report on six years work.

A report is given on the numbers of patients seen and treated by Auckland Hospital varicose veins clinic from May 1974 to May 1980. During this time 2145 patients have been seen in the clinic, 351 of these patients have had leg ulcers and 1191 have been treated by minimum operation with or without injection sclerotherapy. Of these 1191 patients, 84 percent have had their operations as outpatients. The problems of an increasing demand for a good service are mentioned and the necessity for increasing the facilities of the clinic is stressed. It is believed that most patients with varicose veins and venous ulcers can be treated as outpatients and that efforts should be made to increase the numbers so treated in the interests of economy both for the patient and for the hospitals concerned, but that provision should still be made for some patients to be treated as inpatients.

The prevention of post-appendicectomy sepsis by metronidazole and cefazolin: a controlled double blind trial.

A double blind, randomized, controlled trial was carried out at two hospitals to try the effect of metronidazole, which is effective against most anaerobes, and cefazolin, which is effective against many aerobic organisms, singly and in combination, on the incidence of wound sepsis following appendicectomy. Patients were placed at random into one of four groups; to receive metronidazole and placebo, cefazolin and placebo, metronidazole and cefazolin, or double placebo. Patients with generalized peritonitis were excluded for ethical reasons. Treatment was started before operation and continued eight-hourly for twenty-four hours. All patients in the trial were followed up at about two weeks after discharge from hospital and their wounds inspected. Two hundred and seventy-one patients were assessed. Sepsis rates at the two hospitals were similar. On the untreated controls, 30% discharged pus from their wounds, and in the groups receiving one drug only, about 20%. In those receiving both drugs the infection rate was 3%, a highly significant difference from that in the other three groups.

Spinal nerve compression: a cause of claudication.

Thirteen patients were referred with claudication thought by the referring doctor to be vascular in origin. A careful history and physical examination followed by contrast radiculography showed their symptoms to be due to spinal nerve compression. The clinical picture is presented and the main pitfalls in diagnosis is considered. It was stressed that the taking of a careful history is the most important factor in arriving at a correct diagnosis.

Residua of Guillain-Barré Polyneuritis in Children.

A study of the records from the period 1950 to 1970 at the Elizabethtown Hospital for Children and Youth produced twelve patients with the Guillain-Barré syndrome. These patients were contracted in 1975-76 and each was personally examined. Ten were found to have residual weakness but in several instances the weakness was so mild the patient was unaware of it. Good correlations were found between muscle examinations during the acute recovery period and at final follow-up. Six patients had undergone various surgical procedures, and all of them thought they had benefited.

An ionization chamber for therapy-level dosimetry of electron beams.

This ionization chamber has been designed at the National Physical Laboratory in collaboration with the Hospital Physicists' Association; it is especially suitable for use with electron beams below 10 MeV. The sensitive volume is discshaped, 20 mm in diameter and 2 mm deep along the beam axis. Polarity effect is less than 0.1% at energies up to 6 MeV, allowing the chamber to be used with most existing dosemeter electrometers. The chamber is intended to be calibrated by the user against a secondary standard X-ray chamber using a Perspex phantom in 60Co gamma-radiation. Factors for converting 'exposure' readings to absorbed dose in water are tabulated for beam energies up to 7 MeV.